Airway Management and Intubating without Drugs

FiremanMike

EMS Coordinator
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No worries bro 🙂

Just different systems, our folks get 2-3 tubes a shift on average.
Definitely would have loved to work in a system like KC..

That said - you should look up the Driver et al study on the Bougie, 10-12% first pass success rate increase between styles and Bougie, and that’s in a well lit ER with plenty of hands, I think you guys would see a similar increase.
 

rescue1

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Are you saying every medic unit is getting 2-3 tubes a shift, or that among all 9 units there are 2-3 per shift? Because one of those seems very....aggressive haha
 

KingCountyMedic

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2-3 tubes a shift?

X how many paramedics?
18 + 1 MSO per shift I think we’re around 76
Are you saying every medic unit is getting 2-3 tubes a shift, or that among all 9 units there are 2-3 per shift? Because one of those seems very....aggressive haha

My bad, that’s 2-3 per Medic unit during the busy months. Some units are super busy, a couple are fairly slow. We run dual Medics in every rig so usually each Medic will get one or two depending on the location and what the system is doing. Our busiest Medic unit last year had more intubations than all of Shoreline Medic One units combined. Between CPR, shootings and car crashes in the summer our number of intubations skyrocket.
 

Remi

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18 + 1 MSO per shift I think we’re around 76



My bad, that’s 2-3 per Medic unit during the busy months. Some units are super busy, a couple are fairly slow. We run dual Medics in every rig so usually each Medic will get one or two depending on the location and what the system is doing. Our busiest Medic unit last year had more intubations than all of Shoreline Medic One units combined. Between CPR, shootings and car crashes in the summer our number of intubations skyrocket.
I’d love to see a study on the outcomes there vs. other comparable cities. No other study has ever defended such aggressiveness in prehospital airway management.
 

rescue1

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In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it.


@KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).
 

FiremanMike

EMS Coordinator
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In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it.


@KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).
It’s possible, given their reportedly highly functioning tiered systems. The impression they give is that their paramedics truly treat and transport sick als patients, and the rest are taken by FD staffed BLS ambulances..
 

KingCountyMedic

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In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it.


@KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).

I'm looking for some of our more recent data, I agree I think I'm off on my numbers a bit. A lot of our data that gets released is a combination of all King County and Seattle at times. In South King County where we are a true third service (not firefighters) we staff 9 Medic Units, 1 BC MSO that is 24hrs and a Paramedic, and 4 day time MSO positions that are all Paramedics. We do more intubations than Seattle and the north ends of King County, quite a bit more. We have the lowest income, most gangs, drugs and such so we see a lot more sick folks than the rest of our area. Our average is well above 16 a year but no where near 100 per year I think it's probably around 25 or so. We also have a large amount of overtime always available so it's not uncommon for our heavy OT workers tube numbers to really blow up. Personally I think the most I've ever done in 24 hours was 4-5 and that was on some crazy days. If you want to intubate a lot we are looking at huge numbers of retirements in the next 3 years. We are required 12 a year per Medic or you get to go to Harborview's OR to get up to the magic 12. No field Medics ever have to do this, just the day shift folks. (In our Zone, the rest of Seattle and North King County do have to send folks to the OR for tubes)
 

rescue1

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I'm looking for some of our more recent data, I agree I think I'm off on my numbers a bit. A lot of our data that gets released is a combination of all King County and Seattle at times. In South King County where we are a true third service (not firefighters) we staff 9 Medic Units, 1 BC MSO that is 24hrs and a Paramedic, and 4 day time MSO positions that are all Paramedics. We do more intubations than Seattle and the north ends of King County, quite a bit more. We have the lowest income, most gangs, drugs and such so we see a lot more sick folks than the rest of our area. Our average is well above 16 a year but no where near 100 per year I think it's probably around 25 or so. We also have a large amount of overtime always available so it's not uncommon for our heavy OT workers tube numbers to really blow up. Personally I think the most I've ever done in 24 hours was 4-5 and that was on some crazy days. If you want to intubate a lot we are looking at huge numbers of retirements in the next 3 years. We are required 12 a year per Medic or you get to go to Harborview's OR to get up to the magic 12. No field Medics ever have to do this, just the day shift folks. (In our Zone, the rest of Seattle and North King County do have to send folks to the OR for tubes)
Got it, that makes a lot more sense.

I'm not really qualified anymore to apply to EMS jobs, but I was looking at your EMS fellowship down the road, depending on how my training goes.
 

KingCountyMedic

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Got it, that makes a lot more sense.

I'm not really qualified anymore to apply to EMS jobs, but I was looking at your EMS fellowship down the road, depending on how my training goes.
You mean the UW Medical Program? It’s a pretty good one. You’d get to ride with us a lot. The ED Fellows have to ride Seattle Aid Cars, Medic One rigs, and I think they end up doing fixed wing and helicopter time with Airlift NW
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN
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I remember the early days where all of us, including ED Physicians did mostly nasal intubations on these patients. I remember lots of vomit, blood, aspiration etc. In the late 80's early 90's Succinylcholine started getting used around here. Usually with no sedatives or pain control. The way we used to manage airways was absolutely barbaric. It's sad that it's still fairly close to this in many communities. Yes you can sedate the **** outta someone and cram a tube in them but it's this practice that keeps our profession from being a respected profession in the medical community. If you are going to pass an endotracheal tube through a persons cords you should have every tool in your tool box to be successful, including all the RSI drugs and rescue devices. AND you should be required to maintain proficiency at the skill by passing at least 12 ET's a year with complete documentation of the procedure including airway grade, number of attempts, ETCO2 etc.

If you don't have ETCO2 and full RSI protocols with the ability to do it A LOT you probably have no business doing it.

My opinion.
I sure as hell wish we would have had RSI and capnography back in my day (80's)! We never got around to Sux although it was talked about.
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN
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I think the advent of CPAP has helped tremendously. As I can't RSI/DSI at my full-time place, I am more inclined to stick with CPAP if the patient remains hemodynamically stable with a decent respiratory drive even if they are somewhat more obtunded than perhaps the book teaches as acceptable. We are in at least a 1:1 provider/patient ratio here so I feel that there is adequate "reaction time" to a loss of airway reflexes.

I could also attempt to hurricane spray the crap out of someone, that seems like a bad choice. At the very worst, surgical crics are in the standard scope for every Colorado paramedic.

I am still happy that we will have a Ketamine/Roc RSI guideline by the end of the year. I was hoping we could carry over the "Ketamine facilitated airway management" guideline from previous/now PRN spot but alas...
How frequently are crics being done in CO?
 

KingCountyMedic

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How frequently are crics being done in CO?
I can't speak for CO but I know here WA they went down after the Eschmann Bougie was added many years ago by most agencies and then they dropped even further once we added the iGel. I think the majority of surgical airways we end up doing in the last few years have mostly been burn patients. I have actually been able to slip a bougie into the airway using the iGel.
 

Tigger

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When I got on at a HEMS outfit in Vegas we had the full kit and caboodle of critical care interventions and medications. If they had a pulse, they got a full compliment of RSI drugs.
If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.
 

RocketMedic

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If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.
A lot of medics out there think anything that isn’t a full arrest needs the full suite of RSI drugs because protocol. It’s not good medicine.
 

Tigger

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Tigger

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How frequently are crics being done in CO?
I have no idea what the state numbers are. Our system (which is the largest "combined" in the state) probably only does at most five per year over 650k total population.
 
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